<form name="searchForm" id="searchForm" method="POST" action="<?=$_SERVER['REQUEST_URI']?>">
	<div id="main-form" class="patient-search-filter">
		<div class="detail-grouping">
			<p>
				<span>Title</span>
				<span style="margin-left:41px;">Surname</span>
				<span style="margin-left:75px;">Firstname</span>
				<span style="margin-left:70px;">Middle Name</span>
			</p>
			<p>	
				<span><input type="text" name="title" id="title" style="width:50px;" /></span>
				<span><input type="text" name="lname" id="lname" style="width:115px;" /></span>
				<span><input type="text" name="fname" id="fname" style="width:115px;" /></span>
				<span><input type="text" name="mname" id="mname" style="width:105px;" /></span>
			</p>
			<p>
				<span>Address </span>
				<input type="text" name="address1" id="address1" style="width:372px;" />
			</p>
			<p>
				<span>City</span>
				<input type="text" name="city" id="city" style="width:200px;" />
				<span style="margin-left:10px;">Postal Code</span>
				<input type="text" name="zipcode" id="zipcode" style="width:114px;" />
			</p>
		</div>
		<ul class="main-two-cols patient-details-el filter-resultlist">
			<li class="two-cols-left">
				<div class="detail-grouping">
					<p>Phone</p>
					<p><span>Home </span> <input type="text" name="phone_home" id="phone_home" style="width:140px;margin-left:5px" /></p>
					<p><span>Work </span> <input type="text" name="phone_work" id="phone_work" style="width:140px; margin-left:11px" /></p>
					<p><span>Mobile </span> <input type="text" name="phone_mobile" id="phone_mobile" style="width:140px;" /></p>
				</div>
				<div class="detail-grouping">
					<p>Medicare No.</p>
					<p><input type="text" name="medicare_no" id="medicare_no" style="width:177px;" /></p>
				</div>
			</li>
			<li class="two-cols-right">
				<p><span>Date of Birth</span> <input type="text" name="birthday" id="birthday" style="width:135px;" /></p>
				<div class="detail-grouping">
					<p>Sex</p>
					<p>
						<input type="radio" name="gender" id="gender" value="M"> Male &nbsp;&nbsp;
						<input type="radio" name="gender" id="gender" value="F"> Female &nbsp;&nbsp;&nbsp;&nbsp;				
					</p>
				</div>
				<p><span>Record No.</span> <input type="text" name="record_no" id="record_no" style="width:198px;" /></p>
			</li>
		</ul>
		<div class="detail-grouping" style="margin-top:-25px">
			<p>Pension Status</p>
			<p>
				<input type="radio" name="pension_status" value="none"> None &nbsp;&nbsp;
				<input type="radio" name="pension_status" value="pension/hcc"> Pension/HCC &nbsp;&nbsp;
				<input type="radio" name="pension_status" value="limited dva"> Limited DVA &nbsp;&nbsp;
				<input type="radio" name="pension_status" value="full dva"> Full DVA &nbsp;&nbsp;
			</p>
			<p>
				<span>Pension No.</span>
				<input type="text" name="pension_no" id="pension_no" style="width:70px;" />
				<span style="margin-left:5px;">DVA No.</span>
				<input type="text" name="dva_no" id="dva_no" style="width:70px;" />
				<span style="margin-left:5px;">Safety Net No.</span>
				<input type="text" name="safety_net_no" id="safety_net_no" style="width:66px;" />
			</p>
		</div>
		<br clear="all" />
		<p class="buttons_elements">
			<input type="submit" class="form-button btn" id="submitBtn" value="Search">
			<input type="button" class="form-button btn" id="cancelBtn" value="Cancel" >
		</p>
	</div>
</form>

<script type="text/javascript">
	$( document ).ready(function() {
		$("#birthday").datepicker();
	});
</script>